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Brachytherapy
Approximately 229,000 new cases of prostate cancer are diagnosed each year, making it the most common solid, non-dermatologic tumor, found in men. Although the majority of men given the diagnosis will not die from the disease, there are 30,000 prostate cancer deaths each year. Because PSA testing has allowed the diagnosis to be made in younger and younger men, we are constantly looking at ways to improve therapy, hoping not only to increase our patient's longevity, but also to allow them to maintain an excellent quality of life.
Brachytherapy, also known, as radioactive seed implantation is a means of treating prostate cancer whereby seeds composed of radioactive Iodine, Palladium or Iridium are implanted directly into the prostate gland. Depending on the PSA, and the Gleason score, brachytherapy is either done alone, or in conjunction with external beam radiation therapy. In cases where the prostate is very large, or in cases involving high-grade tumors, hormonal therapy may be a part of the treatment. Brachytherapy is contraindicated in cases where voiding symptoms are severe, as well as in cases where the tumor has obviously extended outside of the confines of the prostate.
Current controversy exists as to age cut offs for institution of brachytherapy. Despite 15 year data showing comparable disease free survival statistics between brachytherapy and radical prostatectomy, some physicians are reluctant to implant men in their 50's. As the results prove to be more durable, however, the average age of the patient choosing brachytherapy is falling. The upper age limit for this therapy is dictated by the physiologic age of the patient, with some implants being done in healthy men in their 80's. If you are in your 50's and desire brachytherapy, discuss this issue with your physician.
It is the practice of our group to offer our patients a consultation with a radiation oncologist. If brachytherapy is a consideration, the radiation oncologist will receive a summary of the clinical data, prior to your visit.
If the decision is made to go ahead with brachytherapy, a volume study of the prostate is scheduled through the radiation oncologist. This study is done to determine the size of the prostate as well as to provide parameters for determining the number and location of each of the seeds. Prior to your volume study, it is advised that you give yourself a Fleets™ enema. This procedure is done under local anesthesia, so fasting is not required. You will be able to transport yourself to and from the facility on your own, and to resume normal activity upon leaving the facility. In rare instances, the volume study can be completed utilizing conscious sedation. Occasionally the gland volume will be found to be too large to be practical for implantation. In these cases, the pubic arch may prove to be problematic in allowing for optimal seed distribution. If this is the case, the patient will be offered the option of hormonal downsizing. With an injection of a medication known as a LH-RH agonist (Lupron, or Zoladex e.g.) the gland volume will decrease by up to 30% in about 3-4 months allowing for implantation to take place.
Once we have confirmation of a reasonable gland volume, the procedure will be scheduled as a joint effort between your urologist and the radiation oncologist. Since anesthesia is required, we will ask that you receive medical clearance from your primary care physician. This will include laboratory studies, EKG and a chest x-ray if not done recently. You will be instructed to discontinue all medications that impair blood clotting, such as aspirin, anti-inflammatories, plavix, and coumadin, 7 days prior to the procedure. Discuss the timing for restarting these drugs, with your physician. On the evening prior to the procedure, have nothing to eat or drink after midnight. On the morning of the procedure, you should give yourself another enema.
The implant procedure is done as same day (outpatient) surgery. General or regional anesthesia is required. The actual implant will take about 1 hour. Cystoscopy (telescopic examination of the bladder), is done in every case, at the conclusion of the procedure. A decision to leave a foley catheter draining the bladder is made at that time. If a catheter is placed, the patient is taught how to remove it on the first postoperative day.
A postoperative appointment is scheduled with your urologist for 2 weeks after the procedure. You will see the radiation oncologist 1 month after the procedure, at which time a post implant CT scan will be done to assess the adequacy of the implant. In some instances, the CT scan is completed on the day of the implant. The first PSA will not be done until 4 months following the implant. Follow up after that will be alternated between the urologist, and the radiation oncologist.
The most common post implant symptoms encountered by our patients include urinary urgency, frequency, as well as burning on urination. There are usually some black and blue marks from the puncture sites. The discoloration may often include the scrotum, and rarely the penis. A rare individual will have problems with urinary retention or frequent bowel movements. Urinary, or rectal bleeding is extremely rare. Alpha-blockers, which are given to help improve the urinary flow, are generally started days to weeks prior to the procedure. You may benefit from doubling the dose of the alpha-blocker for 2-3 days following the procedure. Discuss this with your physician. Upon discharge from the operative facility, each of our patients is given a prescription for analgesics, anti-inflammatories, and antibiotics.
Once you are home, an ice pack to the perineum may help with some of the discomfort, along with the prescribed analgesics. You may shower the day following the procedure, and resume normal activity as long as you are comfortable. Sexual activity should be avoided for 1 month. You may safely be in the same room with small children, or pregnant women, but should avoid contact such as having the child sit in your lap. Again, 1 month is reasonable.
Approximately 10 half-lives are required for the radioisotope to lose its entire radioactivity. The half-life for iodine is 60 days, while for palladium it is 16. If you are planning air travel during this period of time, please tell us so that we may provide you with documentation should you trigger low-level radiation detectors at the airports!
Please feel free to contact us for an appointment to discuss the particulars of your case. Our physicians have extensive experience with brachytherapy, as well as radical prostatectomy, and are able to compare and contrast these complicated procedures.